Clinical Color Vision Testing and Correlation
With Visual Function
JIAWEI ZHAO, SARITA B. DAVE, JIANGXIA WANG, AND PREM S. SUBRAMANIAN

PURPOSE: To determine if Hardy-Rand-Rittler (H-R-R)
and Ishihara testing are accurate estimates of color vision in
subjects with acquired visual dysfunction.

DESIGN: Assessment of diagnostic tools.

METHODS: Twenty-two subjects with optic neuropathy
(aged 1865) and 18 control subjects were recruited pro-
spectively from an outpatient clinic. Individuals with visual
acuity (VA) <20/200 or with congenital color blindness
were excluded. All subjects underwent a comprehensive
eye examination including VA, color vision, and contrast
sensitivity testing. Color vision was assessed using H-R-R
and Ishihara plates and Farnsworth D-15 (D-15) discs.
D-15 is the accepted standard for detecting and classifying
color vision deficits. Contrast sensitivity was measured
using Pelli-Robson contrast sensitivity charts.

RESULTS: No relationship was found between H-R-R
and D-15 scores (P [ .477). H-R-R score and contrast
sensitivity were positively correlated (P [ .003). On multi-
variate analysis, contrast sensitivity (b [ 8.61, P < .001)
and VA (b [ 2.01, P [ .022) both showed association
with H-R-R scores. Similar to H-R-R, Ishihara score did
not correlate with D-15 score (P [ .973), but on multivar-
iate analysis was related to contrast sensitivity (b [ 8.69,
P < .001). H-R-R and Ishihara scores had an equivalent
relationship with contrast sensitivity (P [ .069).

CONCLUSION: Neither H-R-R nor Ishihara testing
appears to assess color identification in patients with optic
neuropathy. Both H-R-R and Ishihara testing are
correlated with contrast sensitivity, and these tests may
be useful clinical surrogates for contrast sensitivity
testing. (Am J Ophthalmol 2015;160(3):547552.
2015 by Elsevier Inc. All rights reserved.)
C
OLOR VISION TESTING IS A ROUTINE PART OF THE
neuro-ophthalmologic examination and often is
used by comprehensive ophthalmologists to screen
for suspected optic neuropathy in patients with new visual
Supplemental Material available at AJO.com.
Accepted for publication Jun 16, 2015.
From the Wilmer Eye Institute, The Johns Hopkins University School
of Medicine, Baltimore, Maryland.
Prem S. Subramanian is now at the University of Colorado School of
Medicine, Department of Ophthalmology, Aurora, Colorado.
Inquiries to Prem S. Subramanian, Department of Ophthalmology,
University of Colorado School of Medicine, 1675 Aurora Ct, Aurora,
CO 80045; e-mail: prem.subramanian@ucdenver.edu
0002-9394/$36.00 2015 BY ELSEVIER INC. ALL
http://dx.doi.org/10.1016/j.ajo.2015.06.015
complaints. Color vision testing also may be used to diag-
nose and follow progression of disease and monitor the
onset of toxicity from some medications.15 Commonly
used and easily accessible color vision tests include the
pseudoisochromatic plates, such as the Hardy-Rand-
Rittler (H-R-R) and Ishihara tests, and arrangement tests,
such as the Farnsworth-Munsell 100 and Farnsworth D-15
hue discrimination test.
Pseudoisochromatic plate testing is inexpensive, readily
available, and quickly administered; therefore it is the test
of choice that clinicians use in the evaluation of their pa-
tients with suspected or known optic neuropathy.5,6
Pseudoisochromatic plates were originally developed to
disclose the color confusion axes of congenital
dichromatism (protanopia, deuteranopia, and tritanopia)
and function remarkably well at this task.6 Acquired pseu-
doisochromatic plate testing defects often do not respect
these confusion axes, and clinicians thus assign a score
reflecting the number of plates correctly identified. A prior
study showed that pseudoisochromatic plate identification
in patients with optic neuropathy was worse than expected
from visual acuity (VA) loss alone,5 while another showed
that pseudoisochromatic plate test performance declined in
concert with reduced visual acuity and/or visual field loss of
any etiology.7
Arrangement tests require patients to sort colored caps
of fixed chroma into a sequence or into groups. These tests
are designed without assuming that colors are confused
owing to congenital color vision loss, allowing errors to
be made across the color circle and between adjacent
hues.15,8 Moreover, in contrast to pseudoisochromatic
plate testing, arrangement tests allow quantification of
severity of disease and may be more sensitive in
detecting early visual dysfunction.5,6,9 Arrangement
tests have been demonstrated to be very effective in
following and classifying acquired color defects,4,6,10 but
their use has been limited owing to their time-
consuming nature.5,11
Clinicians often use abnormal pseudoisochromatic
plate testing results as evidence for optic neuropathy,
and standard clinical teaching reinforces this idea.12
While patients with optic neuropathy5,13 and retinal
dystrophy14 often have decreased pseudoisochromatic
plate test scores, we have observed that patients with
other conditions such as dry eye syndrome also can
have abnormal pseudoisochromatic plate test scores.
We sought to determine if poor scores on H-R-R and
RIGHTS RESERVED. 547
 TABLE 1. Demographic Data of Patients With Optic TABLE 2. Comparison of Visual Function, Including Color
Neuropathy and Normal Controls Vision Testing, Between Affected Eyes of Patients and
Control Eyes
Patients Controls
(N 22) (N 18) P Valuea Patient Eyes Control Eyes
Test Result (N 31) (N 36) P > jzj
Mean age in years (SD) 48.0 (10.54) 41.3 (11.5) .067
Sex, N (%) .51 H-R-R score (# of plates 19.1 (1.7) 20.0 (0.1) .019
Female 13 (61.5) 13 (72.2) correct)a
Male 9 (38.5) 5 (27.8) Ishihara score (# of plates 15.1 (2.0) 16.0 (0) .043
Ethnicity, N (%) .184 correct)a
White 16 (72.7) 9 (50) D-15 score [15  (number of 14.6 (0.8) 15.0 (0) .040
Black 4 (18.2) 8 (44.4) errors)]a
Asian 1 (.5) 1 (5.6) Contrast sensitivity 1.5 (0.2) 1.7 (0.04) .003
Hispanic 1 (.5) 0 (0) (log units)a
VA (logMAR) 0.06 (0.2) 0.033 (0.1) .288
a
P values determined by Fisher exact test for sex and ethnicity
and t test for age. H-R-R Hardy-Rand-Rittler; VA visual acuity.
Both eyes of control subjects and the affected eye(s) of pa-
tients are included. Mean and standard deviation of each test
result are listed. Linear mixed-effects regression models with a
Ishihara plate testing represent truly aberrant color vision random intercept for patients were used to compare the 2
or indicate a decrement of other psychovisual parameters. groups. All measures of visual function were reduced in the
We hypothesized that reduced pseudoisochromatic plate affected eyes relative to the control eyes, except for visual acuity.
a
test scores would correlate with contrast sensitivity loss Test with results that are significantly different between pa-
and not reflect true color vision defects as determined tient and control eyes at a 0.05.
by color arrangement testing.

the Farnsworth D-15 test (PV-16 Quantitative color

METHODS

SUBJECTS: This study was a prospective clinical investi-
gation. All study procedures were approved in advance of
the study by the Institutional Review Board of the Johns
Hopkins University School of Medicine and adhered to
the requirements of the Health Insurance Portability and
Accountability Act. Informed consent was obtained from
all subjects. Study subjects between ages 18 and 65 were
recruited prospectively from the Wilmer Eye Institute at
the Johns Hopkins Hospital. Patients with acquired optic
neuropathy (glaucoma, ischemic optic neuropathy, optic
neuritis, or compressive optic neuropathy) (n 22) were
included. Control subjects (n 18) had no ocular pathol-
ogy other than corrected refractive error and had no known
neurological disease.
Individuals with best-corrected VA <20/200 at distance
or near equivalent or with congenital color vision deficits
were excluded (patients and controls). All subjects under-
went a comprehensive eye examination, including assess-
ment of best-corrected Snellen acuity, pupillary response,
and funduscopy.

COLOR VISION TESTING: Monocular color vision
testing was done with H-R-R pseudoisochromatic plates
(4th edition; Richmond Products Inc, Albuquerque,
New Mexico, USA), Ishihara pseudoisochromatic plates
(1997 version; Kanehara & Co, Ltd, Tokyo, Japan), and
vision test; Precision Vision, Lasalle, Illinois, USA).
The affected eye or eyes of patients and both eyes of con-
trol subjects were tested.
Pseudoisochromatic plate testing was done under stan-
dardized lighting (basic fluorescent 30 watt bulb) and the
plates were held 30 cm away from the patient at a perpen-
dicular angle to the line of sight. The score for the Ishi-
hara test was set as the number of plates identified out
of the first 15 screening plates. Scoring followed a stan-
dard clinical rubric. For the 1-digit plate, subjects were
awarded 1 point for correctly identifying the shown num-
ber and 0 points for not seeing or incorrect identification.
For the 2-digit plate, subjects were awarded 1 point for
correctly identifying both numbers on the plate, half a
point for identifying 1 number, and 0 points for not seeing
or incorrect identification of both numbers. The score for
the H-R-R test was set as the number of plates identified
out of the 20 screening and diagnostic plates (numbers
5-24). For plates containing 1 shape, subjects received 1
point for correctly identifying the figure and 0 points for
not seeing or incorrect identification. For plates contain-
ing 2 shapes, subjects received 1 point for correctly iden-
tifying both figures, half a point for identifying 1 shape,
and 0 points for not seeing or incorrect identification of
both shapes. The Farnsworth D-15 test consists of 15
colored discs comprising the entire color spectrum. Un-
der simulated natural daylight conditions (OttLite 508
illumination, Tampa, Florida), subjects were asked to
arrange the discs in order, according to the color, on a

548 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 2015

FIGURE 1. Evaluation of potential correlation between Hardy-Rand-Rittler scores and other clinical tests of visual function. Data
from 31 eyes (22 patients) with optic neuropathy are shown. Scatterplots show Hardy-Rand-Rittler (H-R-R) scores on the y-axis
with Farnsworth D-15 score or contrast sensitivity on the x-axis. (Left) No significant correlation found between H-R-R score
and Farnsworth D-15 score (Kendall correlation [ 0.058, P [ .477). (Right) Correlation is seen between H-R-R score and contrast
sensitivity (Kendall correlation [ 0.314, P [ .003).

statistical association of nonparametric data pairs, was

TABLE 3. Multivariate Analysis of Contrast Sensitivity, Visual used to measure the correlations between the following
Acuity, Age, and Farnsworth D-15 and Their Association With pairs of variables in affected patient eyes: H-R-R score
Hardy-Rand-Rittler Test Scores in the 31 Eyes of Optic
and contrast sensitivity, H-R-R score and Farnsworth D-
Neuropathy Patients
15 score, Ishihara score and contrast sensitivity, and Ishi-
Coefficient 95% Confidence hara score and Farnsworth D-15 score. A multivariate
Variable (Beta) Interval P > jzj linear mixed-effects model also was employed to deter-
Contrast 8.611a 6.94310.279 <.001 mine the association of contrast sensitivity with H-R-R
sensitivity and Ishihara score in affected patient eyes; fixed effects
Visual acuity 1.486 0.1813.153 .081 included contrast sensitivity, visual acuity, age, and Farns-
Age 0.026 0.0120.064 .172 worth D-15 score. A random intercept for patients was
D-15 0.274 0.5630.015 .063 used to account for the correlation between the right
a
and left eyes from the same patient. Statistical analysis
indicates coefficient that is significant at a 0.05.
was performed using Stata 12.1 (StataCorp LP, College
Station, Texas, USA). A P value of < _.05 was considered
statistically significant.
black-colored surface. One point was deducted from a
maximum score of 15 for each misplaced disc.

CONTRAST SENSITIVITY TESTING: Contrast sensitivity RESULTS

was assessed monocularly and binocularly using the Pelli-
Robson contrast sensitivity charts at 1 m. The same light-
ing apparatus used in pseudoisochromatic plate testing was
employed to uniformly illuminate the charts. The faintest
triplet for which at least 2 of the 3 letters were correctly
identified indicated the log contrast sensitivity score of
the tested eye(s).

STATISTICS: Descriptive statistics (Fisher exact for
ethnicity and sex and t test for age) were used to compare
demographic data between the patients and controls. To
account for the correlation between left and right eyes
from the same subject, linear mixed-effects regression
models with a random intercept for patients were used
to test the difference between patient and control eyes
in terms of tests results from H-R-R, Ishihara, and D-15;
contrast sensitivity; and visual acuity. The Kendall
tau correlation coefficient, which is used to determine
TWENTY-TWO ELIGIBLE PATIENTS WERE IDENTIFIED, OF
whom 9 had bilateral disease. Six had optic neuritis, 5
had nonarteritic anterior ischemic optic neuropathy
(NAION), 8 had compressive optic neuropathy, 1 had
glaucoma, 1 had idiopathic noncompressive optic neurop-
athy, and 1 had optic nerve hypoplasia. Eighteen subjects
with no ocular pathology other than corrected refractive
error were identified as controls. Demographic data for pa-
tients and controls are shown in Table 1. Comparison of vi-
sual function between affected patient eyes and control
eyes is presented in Table 2. Patients with bilateral disease
had both eyes tested, giving a total of 31 eyes, and both eyes
(n 36) of control subjects were included in all analyses.
Contrast sensitivity, H-R-R score, Ishihara score, and D-
15 score were significantly reduced in affected eyes
compared to control eyes, although Snellen visual acuity
was not (Table 2).

VOL. 160, NO. 3 COLOR VISION TESTING AND CONTRAST SENSITIVITY 549
FIGURE 2. Evaluation of potential correlation between Ishihara scores and other clinical tests of visual function. Data from 31 eyes
(22 patients) with optic neuropathy are shown. Scatterplots display Ishihara scores on the y-axis and Farnsworth D-15 score or
contrast sensitivity on the x-axis. (Left) No correlation found between Ishihara score and D-15 score (Kendall correlation [
0.002, P [ 1.0). (Right) Correlation between Ishihara score and contrast sensitivity did not reach statistical significance in this
analysis (Kendall correlation [ 0.148, P [ .055).

correlation between contrast sensitivity and the Ishihara

TABLE 4. Multivariate Analysis of Contrast Sensitivity, Visual score was found (Kendall coefficient 0.148, P .055)
Acuity, Visual Field Deficit, Age, and Farnsworth D-15 and in this pairwise analysis (Figure 2). However, contrast
Their Association With Ishihara Test Scores in the 31 Eyes of
sensitivity was associated with the Ishihara score (P <
Optic Neuropathy Patients
.001) when multivariate analysis was performed
Coefficient 95% Confidence (Table 4). Additionally, this multivariate analysis showed
Variable (Beta) Interval P > jzj that age was associated with Ishihara score (P .014). Vi-
Contrast sensitivity 6.869 a
3.73410.003 <.001 sual acuity (P .367) and Farnsworth D-15 score (P
Visual acuity 1.542 1.8124.895 .367 .254) were not associated with the Ishihara score in the
Age 0.072a 0.0140.128 .014 multivariate analysis, showing that no relationship exists
D-15 0.376 1.0210.270 .254 between color identification on the Farnsworth D-15 test
a
and the number of Ishihara plates correctly recognized
indicates coefficient that is significant at a 0.05. (Supplemental Tables 1-3, available online at AJO.com).

COMPARISON OF HARDY-RAND-RITTLER AND ISHI-

ANALYSIS OF HARDY-RAND-RITTLER TEST: Using the
Kendall correlation (Figure 1), we found no correlation be-
tween H-R-R score and Farnsworth D-15 score (Kendall
coefficient 0.058, P .477) in the affected eye(s) of pa-
tients; however, H-R-R score and contrast sensitivity had a
positive correlation (Kendall coefficient 0.314, P
.003), indicating that a decrease in contrast sensitivity
threshold was associated with poorer H-R-R plate identifi-
cation. Multivariate analysis (Table 3) was employed to
evaluate potential effects of other variables such age and
visual acuity. We found that only contrast sensitivity
threshold was significantly associated with H-R-R scores
(P < .001), while age, visual acuity, and Farnsworth D-15
scores were not (P .172, P .081, and P .063, respec-
tively). Thus, accuracy of color identification on the Farns-
worth D-15 test did not show a significant relationship with
the number of H-R-R plates identified correctly.

ANALYSIS OF ISHIHARA TEST: Similar to findings on
H-R-R testing, no correlation was found between Ishihara
score and Farnsworth D-15 score in the affected eye(s) of
patients (Kendall coefficient 0.002, P .973) using
the Kendall correlation. Additionally, no significant
HARA TESTS: Comparison of the Kendall correlation coef-
ficients of H-R-R score and contrast sensitivity to Ishihara
score and contrast sensitivity showed that neither test had a
stronger correlation with contrast sensitivity than the other
(P .069).
DISCUSSION
PATIENTS WITH A VARIETY OF OPTIC NERVE DISORDERS WERE
found to have abnormal performance on pseudoisochromatic
plate testing. We have shown that neither H-R-R nor
Ishihara plates appear to assess true color recognition based
on comparison of pseudoisochromatic plate testing with
D-15 testing. Instead, they both appear to correlate with
contrast sensitivity on multivariate analysis, although only
H-R-R score correlated with contrast sensitivity on pairwise
analysis using the Kendall coefficient. Neither H-R-R nor
Ishihara scores were decreased as a function of visual acuity
in multivariate analysis, which stands in contrast to a previ-
ous study in which H-R-R, Ishihara, and D-15 scores declined
with experimental reduction (by fogging) of visual acuity in
normal subjects.7 In the current study, Ishihara score, but not

550 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 2015

H-R-R, was reduced with age in affected eyes of patients with
optic neuropathy.
H-R-R and Ishihara plates have colored dots of variable
size, hue, and saturation that are arranged into simple
shapes or numbers in a background of similar dots. Pseudoi-
sochromatic plates have been reported to have luminous
reflectance differences between the figure and back-
ground.15 Such differences alter color perception16 and
can reduce color figure detection against a gray background
as luminance is changed.17 This design strategy is very
effective for detecting congenital color vision defects by
hiding the figures in a background but may introduce un-
wanted contrast-related elements.
A prior study showed that H-R-R is more sensitive than
Ishihara testing in identifying patients with optic neuropa-
thies.13 Although only H-R-R results had a significant corre-
lation with contrast sensitivity in pairwise testing, the
multivariate analysis showed both H-R-R and Ishihara tests
to have a strong correlation with contrast sensitivity and no
significant difference between them in this regard. Reduced
contrast sensitivity has been described in the majority of pa-
tients with demyelinating disease even in the absence of clin-
ical optic neuropathy.18 Poor contrast sensitivity may precede
the onset of optic neuropathy in thyroid eye disease patients as
well.19 Low-contrast vision testing may tell the examiner
more about the function of the parvocellular retinal ganglion
cells, which sustain damage in compressive and demyelin-
ating optic neuropathies.20,21 Measuring contrast sensitivity
in the clinical setting is hampered by time constraints and
poor reliability or variability in test results owing to
lighting, reflections, and fading of the charts.22 We propose
that H-R-R or Ishihara testing may be used as an alternative
means of detecting reduced contrast sensitivity in patients
with optic neuropathy, based on our findings.
Limitations of our study include the relatively small sam-
ple sizes of patients and controls, the limited variety of op-
tic nerve diseases, and the selection of Farnsworth D-15 test
as our standard color vision test vs Farnsworth-Munsell
100. Farnsworth-Munsell 100 is more sensitive in the
detection of acquired color vision deficiency23 but requires
prolonged concentration of the patients and may have a
higher number of false-positive results.11 We examined
patients with optic neuropathy and cannot extend our find-
ings to patients with other causes of vision disturbance. We
did evaluate a patient with dry eye syndrome and 3 patients
with retinal dystrophy and obtained similar findings (data
not shown). Therefore, we are currently studying a larger
cohort of patients with dry eye, which reduces contrast
sensitivity,24 in order to expand upon our observations.
In conclusion, this study was intended to explore if
apparent color vision deficits measured by H-R-R and Ishi-
hara tests represent true color vision impairment or indi-
cate reduction in other psychovisual parameters, such as
contrast sensitivity or visual acuity. Our findings show
that H-R-R or Ishihara tests may be used as inexpensive
and readily available surrogate measures of contrast sensi-
tivity. Pseudoisochromatic plate tests were designed to
identify congenital color vision deficits, and clinicians
should not rely upon them to identify patients with ac-
quired color vision abnormalities.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST.
Financial Disclosures: J.W.: NEI, grant support; P.S.S.: NEI, grant support; US Department of Defense, grant support; Stryker Corp (Kalamazoo, Michi-
gan), grant support; Novartis AG (Basel, Switzerland), grant support; National Aeronautics and Space Administration, consultant; Wolters Kluwer (Balti-
more, Maryland), royalties; CME Solutions, Inc (Tucson, Arizona), payment for educational material development, travel expenses for meeting
presentations; various law firms, expert witness testimony. Funding/Support: Supported in part by an unrestricted grant to the Wilmer Eye Institute
from Research to Prevent Blindness, USA and Wilmer Biostatistics Core Grant EY01765. All authors attest that they meet the current ICMJE require-
ments to qualify as authors.

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SEPTEMBER 2015
 SUPPLEMENTAL TABLE 1. Relationship Between SUPPLEMENTAL TABLE 3. Comparison of Visual Function
Farnsworth D-15 and Hardy-Rand Rittler When Considering Between Patients With Optic Neuropathy and Normal
Contrast Sensitivity in Patients With Optic Neuropathy Farnsworth D-15 but Abnormal Hardy-Rand-Rittler or
Ishihara Results, and Patients With Optic Neuropathy and
Variable Coefficient (Beta) P > jzj Normal Hardy-Rand-Rittler or Ishihara but Abnormal D-15
a
Results
HRR 0.244 .023
Contrast sensitivity 2.266a .019 Normal D-15, Abnormal D-15,
Abnormal Normal PIP
HRR Hardy-Rand Rittler. Visual Function PIP (n 10) (n 6) P > jzj
a
Indicates coefficient that is significant at a < 0.05.
Contrast sensitivity 1.65 (0.91.65) 1.65 (1.51.65) .532
(log units)
VA (logMAR) 0 (0.10.3) 0 (0.10) .567

PIP pseudoisochromatic plates; VA visual acuity.

SUPPLEMENTAL TABLE 2. Relationship Between
Wilcoxon rank sum test was used to compare the 2 groups.
Farnsworth D-15 and Ishihara Plate Testing, Accounting for
Median and range of each test result are shown.
Contrast Sensitivity, in Patients With Optic Neuropathy

Variable Coefficient (Beta) P > jzj

Ishihara 0.12 .092

Contrast sensitivity 1.22 .089

VOL. 160, NO. 3 COLOR VISION TESTING AND CONTRAST SENSITIVITY 552.e1
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.